7.1.6. LHSS Annual Report 2023.pdf

USAID.GOV UHI FY4 ANNUAL REPORT - OCTOBER 2023-SEPTEMBER 2024 | 1

Urban Health Initiative

Project Year 4 Annual Report – October 1, 2023, to September 30, 2024

Cover Photo

Disclaimer

Urban Health Initiative is a five-year U.S. Agency for International Development (USAID) project in Afghanistan, implemented by a consortium led by Jhpiego Corporation, in partnership with Management Sciences for Health, CARE, Intellecap, Agency for Assistance and Development of Afghanistan, Afghan Midwives Association, Afghan Social Marketing Organization, BAO Systems, Internews, Project ECHO, Terre des Hommes, and Viamo. This document is made possible by the support of the American people through USAID under the cooperative agreement number 72030620CA00007. The contents of this document are the sole responsibility of Jhpiego Corporation and do not necessarily reflect the views of USAID or the U.S. Government.

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TABLE OF CONTENT

Abbreviations 6 Project Overview 8 Executive Summary 9

Objective 1: Strengthen the health service delivery ecosystem in urban areas to deliver high-quality services to the most vulnerable 9 Objective 2: improve access for vulnerable populations to critical primary and lifesaving secondary and referral care health services in urban areas through the public and private sectors 10 Objective 3: improve the quality of public and private critical primary and lifesaving secondary and referral health services in urban areas 16 Objective 4: improve awareness, demand, and care-seeking for key services and referral 19

Summary of Achievements in Year 4, Annual Report (October 01, 2023–September 30, 2024) 20

Introduction 24

Work environment in FY4 24

Activity Implementation Progress 24

Objective 1: Strengthen the health service delivery ecosystem in urban areas to deliver high-quality services to the most vulnerable 24 Objective 2: To improve access for vulnerable populations to critical primary and lifesaving secondary and referral care health services in urban areas through the public and private sectors 26 Objective 3: Improve the quality of public and private critical primary and lifesaving secondary and referral health services in urban areas 51 Objective 4: improve awareness, demand, and care-seeking for key services and referral 66

Cross-Cutting Issues 75

C.1 Restriction on female staff working with Nongovernmental organizations 75 C.2 Personnel 75 C.3 Coordination with UHI partners 75 C.4 Coordination with USAID and the stakeholders 75 C.5 Coordination with AFIAT, LHSS, and THIRD-PARTY Monitoring 75 C.6 Monitoring and evaluation 76 C.7 Gender 80

Challenges and Operating environment 81

Annexes 84 Annex 1: Geographic Coverage of UHI Project 84 Annex 2: UHI Consortium Partner Focus Areas 85 Annex 3: Topics Covered in Learning Sessions 86

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LIST OF TABLES

Table 1: Summary of Project Scope and Financial Update 8

Table 2: Number of HF Stockouts by Period

Table 3: Performance on UHI Annual* Performance Plan and Report Indicators for FY4 20

Table 4: Details of the 2024 AFSOG Symposiums conducted in FY4 26

Table 5: Participation in group ANC meetings and receipt of services by pregnant women invited during

FY4. 27

Table 6: Number of deaths reported and reviewed by MNDSR in targeted HFs in FY4, by type of death

Table 7: TB performance indicators, UHI target provinces, in FY4 32

Table 8: COVID-19 vaccines delivered by COVAX mobile teams by city, sex and type, FY4 36

Table 9: Equipment fixed and installed by the biomedical engineers’ team in FY4 37

Table 10: COVID-19 service delivery in 14 inpatient HFs in FY4, disaggregated by sex 38

Table 11: Services provided by Kabul, Mazar, Herat, and Kandahar MLMCCs, FY4 42

Table 12: Percent of women with a normal birth adopting PPFP (IUCD and implants only), FY4 43

Table 13: FHH achievements in FY4 45

Table 14: Number of clients referred by uCHWs by city, FY4 47

Table 15: Number of clients referred by uCHWs by city in FY4 47

Table 16: Awareness-raising sessions, FY4 49

Table 17: Fixed centers providing psychosocial support to pregnant women during FY4 49

Table 18: Yearly Comparison of HF Refer-in

Table 19: Contraceptives distributed by UHI, FY4 51

Table 20: ECHO sessions conducted by UHI and number of participants at 28 ECHO sites, FY4 51

Table 21: Number of health care providers who participated in learning sessions and were assessed as competent in UHI-targeted HFs, FY4 56

Table 22: Training and orientation conducted in UHI-targeted provinces, FY4 59

Table 23: Comparison by technical area (Q1 vs Q4) 62

Table 24: Summary findings from client exit interviews, FY3 and FY4 by quarter 62

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Table 25: Satisfaction level, overall quality (five parameters) and NPS by round 64

Table 26: Detail of calls, FY4 66

Table 27: ANC starting period 73

Table 28: PNC starting period 74

Table 29: Data management system results in HFs in FY4 by Quarter 78

Table 30: Indicators assessed during DQA visits, by level, FY4 79

LIST OF FIGURES

Figure 1: Percentage of births that received key high-impact interventions at the HF level in FY4, by number and percentage 29

Figure 2: MNH cascade by facility category FY4, by number of births (UHI customized DHIS2) 30

Figure 3: Trend over time, CYP by method, FY4 31

Figure 4: TB performance by HF type, FY4 34

Figure 5: Percent of surgical site infections in 25 safe surgery targeted hospitals, FY4 36

Figure 6: Percent of PPFP acceptance, FY4 43

Figure 7: Service delivery by community midwives in Herat city, FY4 by quarter 44

Figure 8: Service delivery by uCHWs at 209 HPs, FY4 48

Figure 9: Participants in ECHO sessions by program, quarter, and gender, FY4 52

Figure 10: Average number of participants in MNH ECHO sessions, by month and gender, FY4 53

Figure 11: Participants in MNH learning sessions who completed vs. who are competent in UHI-targeted HFs, FY4 54

Figure 12: Participants in FP and postabortion care (PAC) learning sessions who completed vs. who are competent in UHI-targeted HFs, FY4 54

Figure 13: Participants in child health, adolescent health, EPI, newborn, and nutrition learning sessions who completed vs. who are competent in UHI-targeted HFs, FY4 55

Figure 14: Participants in data, pharmacy, and TB learning sessions in UHI-targeted HFs, FY4 55

Figure 15: Participation of providers in COVID-19 learning sessions in UHI-targeted HFs, FY4 56

Figure 16: The significant growth in registrations 67

Figure 17: City-wise registration 68

Figure 18: Percentage contributions 68

Figure 19: Infoline unique users 69

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Figure 20: User engagement 70

Figure 21: Key messages: ANC 71

Figure 22: Total time listened (hours) 71

Figure 23: Key messages: PNC 72

Figure 24: Total time listened (hours) 73

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ABBREVIATIONS

AFIAT Assistance for Families and Indigent Afghans to Thrive AFSOG Afghanistan Society of Obstetricians and Gynecologists AHS Afghanistan Health Survey AMA Afghan Midwives Association ANC antenatal care ANPHI Afghan National Public Health Institute ARI acute respiratory infection BC bacteriologically confirmed BCS Balanced Counseling Strategy BTL below the line CBHC community-based health care CHC comprehensive health center CS cesarean section CYP couple-years of protection DMPA depot medroxyprogesterone acetate DOTS Directly observed treatment, short course DQA data quality assessment DR-TB drug-resistant TB DS-TB drug-susceptible TB ECEB Essential Care for Every Baby ECSB Essential Care for Small Babies ECHO Extension for Community Healthcare Outcomes ENRA Electronical Nominal Registration System EPI Expanded Program on Immunization FHH family health house FP family planning GDI General Directorate of Intelligence HBB Helping Babies Breathe HF health facility HMIS health management information system HP health post ICU intensive care unit IEA Islamic Emirate of Afghanistan IEC information, education, and communication IFA iron-folic acid IPC infection prevention and control

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IRB Institutional Review Board IUCD intrauterine contraceptive device LARC long-acting reversible contraception LHSS Local Health System Sustainability MAM moderate acute malnutrition MCH maternal and child health M&E monitoring and evaluation MEC medical eligibility criteria MEL monitoring, evaluation, and learning MHT mobile health team MLMCC midwifery-led maternity care center MNCH maternal, newborn, and child health MNDSR maternal and newborn death surveillance and response MNH maternal and newborn health MoPH Ministry of Public Health MUAC mid-upper arm circumference NPS net promoter score NTP National TB Control Program OPD outpatient department PAC postabortion care PCR polymerase chain reaction PE/E pre-eclampsia/eclampsia PMDT programmatic management of drug-resistant TB PNC postnatal care PPFP postpartum family planning PPH postpartum hemorrhage PPHD Provincial Public Health Directorate PPIUCD postpartum IUCD QI quality improvement RH reproductive health RHCS Reproductive Health Commodities Security RMNCAH reproductive, maternal, newborn, child, and adolescent health RR rifampicin-resistant SAM severe acute malnutrition SOP standard operating procedure TB tuberculosis TT tetanus toxoid

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uCHW urban community health worker UHI Urban Health Initiative UN United Nations UNFPA United Nations Population Fund USAID United States Agency for International Development USG United States Government WHO World Health Organization WISN Workload Indicators of Staffing Need

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PROJECT OVERVIEW

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EXECUTIVE SUMMARY

The Urban Health Initiative (UHI) is a five-year cooperative agreement (October 14, 2020–October 13, 2025) funded by the United States Agency for International Development (USAID) and implemented by a consortium led by Jhpiego, with Management Sciences for Health, CARE, Intellecap, Agency for Assistance and Development of Afghanistan, Afghan Social Marketing Association, Afghan Midwives Association (AMA), Terre des Hommes, Internews, BAO Systems, Project ECHO, and Viamo.

OBJECTIVE 1: STRENGTHEN THE HEALTH SERVICE DELIVERY ECOSYSTEM IN URBAN AREAS TO DELIVER

HIGH-QUALITY SERVICES TO THE MOST VULNERABLE

During fiscal year 4 (FY4), UHI made progress toward all objectives despite the challenging political situation and worsening gender oppression. The project continued to coordinate activities with the Ministry of Public Health (MoPH) at national and provincial levels to achieve results through the UHI-supported health facilities, family health houses (FHHs), and mobile teams. UHI staff members participated in relevant technical coordination fora and collaborated with other stakeholders through various coordination platforms:

● National-level collaborations include the health cluster; nutrition cluster; reproductive, maternal, newborn, child, and adolescent health (RMNCAH) task force; National Expanded Program on Immunization (EPI); maternal and newborn health (MNH) technical subcommittee; MNH technical working group;

family planning (FP) coordination committee; National Reproductive Health Commodity Security (RHCS) coordination committee; national maternal and newborn death surveillance and response (MNDSR) committee; nutrition task force; child health task force; adolescent sexual and reproductive health coordination working group; and community-based health care (CBHC) and TB task force meetings. Additionally, the UHI team contributed to the revision and development of misoprostol guidelines; oxytocin guidelines; antenatal care (ANC), postnatal care (PNC), and labor care guidelines; National Essential Newborn Care Package, World Health Organization (WHO), Second Edition; and national kangaroo mother care (KMC) guidelines; and led the Labor Care Guide guideline development technical working group.

● City-level collaborations include public health coordination committees (PHCCs); tuberculosis (TB) task force; CBHC subcommittee; RMNCAH subcommittee; EPI subcommittee; nutrition subcommittee; health management information system (HMIS) subcommittee; Centers for Disease Control and Prevention/Emergency Preparedness and Response committee; Harmonized Quality Improvement Program committee; health subcluster; nutrition subcluster; Directorate of Economy;

Agency Coordinating Body for Afghan Relief & Development coordination; quality improvement (QI) committee; MNDSR committee; and health facility (HF) shura meetings.

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UHI regularly coordinated with USAID and other health projects (Assistance for Families and Indigent Afghans to Thrive [AFIAT] and Local Health System Sustainability [LHSS]). Furthermore, the project coordinated with United Nations (UN) agencies (UNICEF, WHO, UN Population Fund [UNFPA], and UN Office for the Coordination of Humanitarian Affairs). UHI is part of the Agency Coordinating Body for Afghan Relief and Development (ACBAR) Women Working Group forum and has active participation in the meetings. Finally, UHI worked with professional associations, the AMA, Afghanistan Society of Obstetricians and Gynecologists [AFSOG], and Afghanistan Nurses and Midwives Council) and private sector stakeholders.

Five AFSOG capacity-building symposiums were successfully conducted with the technical and financial support of UHI in Kabul, Mazar, Herat, and Kandahar cities. The following topics were covered in each city for 601 AFSOG members including obstetrician-gynecologist (ob-gyn) specialists, medical doctors, and midwives (from public and private health facilities):

● B-lynch suture

● Implant insertion and removal

● Hypertension during pregnancy and pre-eclampsia/eclampsia (PE/E) management

● Helping Babies Breath (HBB)

● Fourth degree perineal laceration repair

During FY4, UHI conducted 112 supportive supervision sessions to strengthen service delivery and build capacity in the five target cities. UHI country office technical teams, field implementers, and monitoring and evaluation (M&E) staff actively participated. This led to iterative improvements and enhanced service excellence.

OBJECTIVE 2: IMPROVE ACCESS FOR VULNERABLE POPULATIONS TO CRITICAL PRIMARY AND LIFESAVING

SECONDARY AND REFERRAL CARE HEALTH SERVICES IN URBAN AREAS THROUGH THE PUBLIC AND

PRIVATE SECTORS

2.1 ENGAGE PUBLIC AND PRIVATE HOSPITALS AND HEALTH FACILITIES TO

INCREASE ACCESS TO SERVICES

● Improve service delivery readiness in 76 HFs: UHI supported various service levels (e.g., regional hospitals, specialist hospitals, district hospitals, private hospitals, and other health centers) to strengthen the delivery of integrated services across RMNCAH including FP, newborn, safe surgery, nutrition, EPI, COVID-19, and TB through structured in-person mentoring and telementoring.

In FY4, UHI activities were reported by 50 targeted public HFs and 26 private HFs (see Annex 4, Performance Indicator Summary). UHI support to these HFs enabled significant readiness of essential services and built the potential to

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increase adaptive service delivery capacity in the future. Mentors/clinical specialists were deployed to these HFs to support service providers in improving service delivery readiness as well as continuous quality of services in a resource-constrained setting.

● Maternal health: At the 76 UHI-supported HFs, a total of 219,797 first ANC visits (ANC1) and 254,314 first PNC visits (PNC1) were conducted. The PNC visits are higher in UHI target health facilities (MLMCCs and tertiary hospitals) as it also includes the deliveries at home and private health facilities.

● In addition, 629,403 women were counseled on FP (interval, postpartum, and postabortion); of these, 393,172 (62%) chose an FP method (condoms: 135,525; oral pills: 160,624; depot medroxyprogesterone acetate [DMPA]: 43,543; emergency pills: 15,914; tubal ligation: 3,903;

intrauterine contraceptive device [IUCD]: 14,822; and implant: 18,841). UHI-trained health care providers at these HFs supported 236,800 births. MNDSR committees remained functional in 59 HFs and conducted meetings monthly or based on need.

● Twenty-five hospitals continued to implement safe surgery activities to improve cesarean section outcomes. Group ANC was functional in eight HFs.

● Newborn health: During the reporting period, 324 mentorship sessions were conducted for 521 health care providers on Essential Care for Every Baby (ECEB), Essential Care for Small Babies (ECSB), and HBB. Newborn corners were functional in 64 UHI-targeted HFs.

● Family planning: During the reporting period, 441 mentorship sessions were conducted for 604 health care providers on FP counseling, implant insertion, postpartum IUCD (PPIUCD) insertion, and Sayana Press. Postpartum FP (PPFP) corners were functional in 65 UHI-targeted HFs (Figure 17), and one new corner was established (at Alama Reshad Comprehensive Health Center [CHC] in Kandahar city).

o UHI included U.S. Government (USG) FP and abortion compliance in all capacity-building orientations and monthly technical meetings.

o UHI continued coordinating with the Afghan Family Guidance Association and RMNCAH/MoPH to ensure uninterrupted availability of FP commodities, FP counseling tools, and information, education, and communication (IEC) materials at 69 HFs, considering privacy and confidentiality to ensure voluntarism and informed choices. However, seven of the 35 faced stockouts of FP commodities (implant, IUD, condom, pills) during different time periods.

Table 2: Number of HF Stockouts by Period

Family Planning commodities Dec-2023 Mar-2024 Jun-2024 Sep-2024

Condoms 0 3 12 4

Implant 4 2 0 1

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DMPA 0 1 2 1

IUCD 0 3 1 0

Oral Pills 0 1 0 0

● Child health: During the reporting period, 235 health care providers participated in a total of 604 mentorship sessions on the management of diarrhea, pneumonia, coma/convulsion, severe bacterial infection in children ages 0–2 months (neonatal sepsis), neonatal hypothermia, neonatal hypoglycemia, and prevention and early detection of neonatal jaundice. Health care providers were also equipped with the knowledge and skills to deliver the intended services.

● Adolescent health: During FY4, 16 mentorship sessions were conducted for 113 health care providers on adolescent reproductive health and rights. Guidance notes were developed for midwifery-led maternity care center (MLMCC) midwives on identifying and referring adolescent mothers suffering from mental health disorders for psychosocial support.

The project continued to collect age-disaggregated service delivery data in UHI-targeted sites (FHHs, community midwives, and MLMCCs). The project is reviewing the data monthly/quarterly with the target cities.

● Nutrition: UHI strengthened a functional referral system for malnourished children in targeted HFs. In FY4, UHI-trained nutrition service providers screened 4,701,881 children ages 2–5 years for malnutrition using MUAC.

The providers identified 57,145 children with moderate acute malnutrition (MAM) and an additional 29,086 children with severe acute malnutrition (SAM). In total, 11,480 MAM and SAM cases were referred to HFs that provide treatment for malnutrition. During FY4, nutrition corners were functional in 57 UHI-targeted HFs.

● Tuberculosis: UHI supported the implementation of TB activities in 75 UHI-targeted HFs. In total, 93,330 presumptive TB patients were identified by UHI-trained personnel; of these, 12,137 (13%) were either bacteriologically or clinically diagnosed TB cases: 4,802 pulmonary bacteriologically confirmed (BC)-TB cases and 353 extra-pulmonary BC-TB cases; and 3,758 extra-pulmonary clinically diagnosed and 3,224 pulmonary clinically diagnosed. Out of 12,137 all form of TB cases, USAID.GOV UHI FY4 ANNUAL REPORT - OCTOBER 2023-SEPTEMBER 2024 | 14

8.026 are pulmonary TB cases and 5.155 are bacteriologically confirmed TB cases (42%) in UHI targeted HFs. The national coverage of BC TB is 52.8%.

● A notable increase occurred in the number of all-form TB cases (26%) compared to the FY3 (9,656 all-form TB). Among these cases, 3,493 (4%) were children under the age of 15 years. In FY3, 6,079 TB patients started treatment and 5,689 successfully completed treatment (94% success rate).

During FY4, 216 rifampicin-resistant TB (RR-TB) cases were identified in the UHI coverage area and 121 were referred in from neighboring districts and provinces. A total of 337 RR-TB cases were registered and enrolled for DR-TB treatment at four programmatic management of DR-TB (PMDT) sites. This is 12 (4%) more cases than in FY3.

UHI also provided people with DR-TB with food baskets. In addition, UHI supported additional lab exams, use of CAD4TB machines, provision of cartridges for GeneXpert machines, transportation cost for patients, and support for the transportation of samples.

UHI supports active TB contact investigation in both public and private HFs. During FY4, contact investigation coverage was 48%, outperforming the target of 36%. This was mainly due to implementing active screening and follow-up of household screening within the first two weeks of treatment initiation.

Additionally, the UHI team conducted TB quarterly review workshops in four cities (Mazar, Herat, Kabul, and Jalalabad) with 192 health care providers attending (28 female and 164 male). During these review workshops, TB data was reviewed, feedback was provided to the HF staff, and action plans were developed based on findings. As a result of these review workshops, the accuracy of data, follow-up of referral cases, target setting at HFs, feedback mechanisms, coordination with the National TB Control Program (NTP) and HFs (public and private) improved.

In FY4, DR-TB counselors provided support and health education to the newly enrolled DR-TB patients in four PMDT sites in Kabul, Herat, Nangarhar, and Balkh provinces. Patients received top-up cards for mobile phone calls to manage and report adverse drug reactions in a timely manner.

● COVID-19: During FY4, the project continued to support COVID-19 service readiness in the five cities through mentorship by UHI clinical specialists. Topics included COVID-19 triage, referral, and COVID-19 mechanical ventilator technical assistance. UHI also provided oxygen supply to COVID-19 hospitals. In FY4, UHI supplied 2,621 cylinders of oxygen (each cylinder containing 42 liters of oxygen) to the targeted hospitals (1,816 cylinders to Kabul, 130 cylinders to Jalalabad, 282 cylinders to Kandahar, and 393 cylinders to Mazar-e-Sharif).

During FY4, UHI biomedical engineers conducted training in Mazar on the CAD4TB, with 40 health care

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providers attending. They also repaired 303 pieces of biomedical equipment and 24 other pieces of equipment (baby warmer, CAD4TB, electrolyte analyzer, infusion pump, operating theater lights, and ultrasound machine) and installed eight new pieces of equipment. In addition, the biomedical engineers installed an oxygen piping system in three hospitals (Istiqlal, Malalai, and Indra Gandi). This system connects the USG-donated oxygen concentrator with the hospital wards (intensive care unit [ICU], internal medicine, and cardiac surgery).

● EPI: During FY4, EPI fixed centers remained functional in 69 out of 76 UHI-targeted HFs. A total of 290 mentorship sessions were conducted on topics including vaccine session planning and data registration, vaccine wastage and open vial policy, cold chain management, monitoring charts, and dropout calculation. EPI vaccinator availability is ensured at all targeted HFs.

● Equipment: During FY4, a health facility assessment was conducted to understand the HFs’ current needs and support the enabling environment (equipment, minor renovation, and staffing). UHI procured and supplied equipment and commodities to targeted HFs based on facility needs.

● Waste management: UHI supported health care waste management capacity-building as part of risk mitigation and environmental protection during the reporting period. UHI support to the 76 targeted HFs included the provision of supplies (liquid soap, alcohol handrub, chlorine liquid and powder, plastic aprons, rubber boots, utility gloves, single-use caps and plastic footwear, nonsterile gloves, plastic buckets, red and yellow plastic bags, waste recycling bins, mops, floor brushes, and safety boxes) for proper waste management and technical support/capacity-building and orientation sessions for HF personnel.

● Mobile outreach services: In FY4, four mobile health teams (MHTs) (three in Kabul and one in Jalalabad) remained functional and provided service delivery in underserved areas. Each team comprised one male pediatrician, one female ob-gyn, one sonologist, one midwife, one male nurse, and one lab technician. During FY4, a total of 1,757 ANC1 and 559 PNC1 visits were conducted, and 2,620 women were counseled on FP, of whom 2,005 (77%) selected an FP method. The MHTs provide child health and other outpatient department services in villages. During FY4, a total of 6,511 cough and cold, 6,713 ear, nose, and throat diseases, 5,789 diarrhea, 4,240 anemia, 983 eye infections, 1,885 <2 growth monitoring, 1,003 hypertension, 3,269 peptic disorders, 3,531 urinary tract infections, 989 sexually transmitted infections, and 580 cases of trauma were identified and treated, and 7,787 patients were checked using ultrasonography to support diagnoses and follow-up.

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● MLMCCs: Service delivery continued at the Ahmad Shah Baba district hospital in Kabul and Herat during FY4. Mazar and Kandahar MLMCCs were established and became fully functional during Q2 and Q3. UHI provided technical and logistical support and supplies to the MLMCCs to maintain services. During FY4, a total of 67,445 women were screened and 23,226 gave birth in MLMCCs. All these women received 23,827 PNC1(the PNC1 is higher as the MLMCC also provided PNC services to women delivered at home or other HFs). In addition, 23,161 received FP counseling before discharge; of these, 11,746 (51%) adopted a PPFP method (1,315 PPIUCDs, 2,058 implants, and 8,373 lactational amenorrhea method). All of the women had a companion during all three stages of labor, excluding the time of actual birth; 22,215 (96%) women had a companion at birth; and 11,843 (51%) gave birth in a nonsupine position. A total of 4,282 women were referred to nearest maternity centers.

During FY4, the Kandahar MLMCC was officially inaugurated. UHI also selected the location for the second MLMCC in Kabul and completed the procurement process for equipment and supplies and minor renovation. The new Kabul MLMCC was officially inaugurated on September 30, 2024.

● Community midwifery services: In FY4, 12 community midwives in Herat conducted a total of 4,432 ANC1 and 2,086 PNC1 visits and counseled 7,387 women on FP. Of these women, 7,394 (100%) adopted an FP method (pills, condoms, DMPA and emergency contraceptives). During FY4, these UHI-trained community midwives screened 4,358 children ages 2–5 years old with MUAC to assess their nutritional status and referred 29 children under age 5 to the hospital for SAM or MAM.

Overall, in FY4, 740 clients were referred for services, including 478 deliveries and 155 pregnant women for tetanus toxoid (TT) vaccination.

USAID approved the changes of modality for the community midwifery program in Kandahar. Per the new modality, the community midwives in Kandahar were shifted to the newly established Kandahar MLMCC in Q3, while in Kabul, they were switched to the newly established Isteqlal MLMCC in Q4.

● FHHs: In FY4, UHI continued to support four urban FHHs in rented premises in Jalalabad city. The four FHHs, located in underserved areas of the city, remained functional, with three midwives in each FHH. During FY4, these FHHs provided a total of 5,251 ANC1 and 3,291 PNC1 visits to women of reproductive age. In addition, 8,016 women were counseled on FP (interval, postpartum, and postabortion), of whom 5,196 (65%) adopted an FP method. FHH midwives conducted 2,850 deliveries, 2,594 children <1 year received the pentavalent (Penta 3) vaccine, 2,217 children <1 year received the measles-containing vaccine (MCV1), 8,313 children <2 received growth monitoring, 3,571 pregnant women received TT vaccination, and 471 cases (429 children <5 years with SAM and MAM and 42 presumptive TB) were referred to the nearest HF.

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Courage Club: UHI continued the Courage Club intervention to support the mental health of female staff in Kabul city and expanded to four other cities during the reporting period.

Moreover, UHI conducted Courage Club training of trainers for 13 gender focal points in the five cities.

● Private midwifery: UHI followed up with LHSS on the concept of a reproductive CHC under the Afghan Family Guidance Association. UHI had a few rounds of discussions with LHSS during the year. We were expecting the establishment of the mentioned center with support of LHSS, but it did not take place in FY4. We do not anticipate support in FY5 due to the project closeout.

● Urban health posts (HPs) and urban community health workers (uCHWs): During FY4, through 209 urban HPs in Kabul (105), Jalalabad (24), Mazar (40), and Herat (40), a total of 318,404 families were visited, with 22,136 antenatal visits and 12,009 postnatal visits conducted., 94,980 women counselled on FP, and 22,573 clients accepted (9,810 Oral pills, 4,773 DMPA and 7,990 condoms).

During FY4, 104,419 children ages 2–5 years were screened using MUAC to assess their nutritional status. Overall, in the reporting period, 85,728 clients were referred for services. During FY4, 83 uCHWs received the second phase of initial training, and 127 received refresher training.

In addition, social mobilizers conducted 4,255 awareness-raising sessions (2,331 with women and 1,924 with men) with a total of 65,041 community members (40,341 female and 24,700 male) in Kabul, Herat, Mazar, and Jalalabad. Health topics included mental health, family support, ANC, PNC, TB, HIV, FP, safe drinking water, immunization, balanced food for mothers, Mpox, common diseases, COVID-19 key prevention messages, and hygiene. Community health shuras were functional in all 209 UHI-supported HPs and conducted 2,218 meetings during the reporting period. In addition, nine HF shuras were active and conducted regular monthly meetings (the target is one community health shura meeting/month).

UHI presented the new modality of social mobilization through HFs that was approved by USAID. The UHI social mobilizers are conducting social mobilization sessions through HFs, however the health promoters’ activities stopped based on a letter from the MoPH banning awareness-raising activities at the community level.

● Psychosocial counseling center: During FY4, UHI provided psychosocial support to women through eight HFs in Jalalabad, Kandahar, Mazar, Herat, and Kabul. As part of group ANC (G-ANC) in these HFs, women are screened for prenatal mental health concerns and then referred

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to counselors at the psychosocial counseling center if needed. UHI integrated virtual counseling services into the fixed centers in Q2. Clients initiate the first contact and counselors call them back immediately (or at a time that is convenient for the client), ensuring that the call is free for the client.

During FY4, 350 clients received virtual psychosocial counseling.

2.2 IMPROVE PATHWAYS TO PRIMARY AND SECONDARY CARE FOR MOTHERS, CHILDREN, AND VULNERABLE

POPULATIONS

● Referral system: UHI strengthened the referral system from communities to HFs and from HFs to HFs in the areas of maternal, newborn, and child health (MNCH), nutrition, EPI, and TB.

2.3 IMPROVE AVAILABILITY OF ESSENTIAL MEDICAL AND NON-MEDICAL SUPPLIES IN PUBLIC AND PRIVATE

URBAN HFS

● UHI received contraceptives from the Afghan Family Guidance Association/UNFPA and provided them to the targeted HFs and community programs, which contributed to surpassing the annual target for uptake and couple-years of protection (CYP). In addition, UHI provided regular monthly pharmaceutical supplies to targeted HFs.

OBJECTIVE 3: IMPROVE THE QUALITY OF PUBLIC AND PRIVATE CRITICAL PRIMARY AND LIFESAVING

SECONDARY AND REFERRAL HEALTH SERVICES IN URBAN AREAS

3.1 PUBLIC HOSPITAL RESOURCE HOSPITALS AND REFERRAL SUPPORT

Virtual communities of practice: During FY4, two additional ECHO sites were established at Kandahar Regional Maternity Ward and Nangarhar Fatima ul Zahar Hospital, resulting in a total of 28 ECHO sites. In FY4, 73 ECHO sessions were conducted (24 on TB, 24 on child health, 24 on MNH, and one on general topics) for a total of 16,352 providers (8,705 females and 7,647 males). The sessions were moderated by UHI to ensure structured discussion of case management and peer review on holistic case treatment.

In FY4, a total of 59 MNDSR committees in public and private targeted HFs were functional (33 public HFs and 26 private HFs). The committees reviewed 122 of the 123 maternal deaths and 32% (417) of the 1,304 newborn deaths that occurred in these HFs. These reviews identify the cause, review and identify the gaps in care, and develop action plans with hospital staff.

The leading causes of maternal deaths among these cases were hypertensive disorders of pregnancy, such as PE/E, and obstetric hemorrhage, including postpartum and antepartum hemorrhage. Additional contributors included pulmonary embolism, complications related to abortion/miscarriage, and adverse effects of medical care, such as adverse effects of anesthesia and medications. UHI is supporting action plans to prevent future cases. Please see Annex 6 (MNDSR Committee Meeting Report (Monthly), Maternal death).

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For the 417 newborn deaths reviewed, low birthweight, prematurity, birth asphyxia, and sepsis were the leading causes of death.

3.2 IMPLEMENT MENTORSHIP APPROACH FOCUSING ON MNCH, SAFE SURGERY,

NUTRITION, COVID-19, EPI, TB, AND FP IN TARGET HEALTH FACILITIES

Improving the quality of services through mentorship program implementation: The clinical specialist/mentorship teams are assigned to facilities to work with health care providers over time to identify and address gaps and improve services. The process supports health care providers in terms of the knowledge, skills, competence, and confidence needed to provide quality health services. In addition to mentorship, UHI undertook the following activities to strengthen staff capacity:

● Training of health care workers: In addition to 4,220 onsite mentorship sessions in FY4, UHI provided 182 group trainings, including orientation sessions, to a total of 3,195 health care workers (2,480 female and 715 male).

● Waste management: During FY4, 216 health care providers (119 female and 97 male) were oriented on health care waste management. In addition, 76 HFs (50 public and 26 private) were supported with supplies and consumables, and additional job aids were distributed.

● Safe obstetric surgery: During FY4, the safe surgery checklist was applied/completed in 44,057 (94%) of 46,715 cesarean births in 25 targeted hospitals where cesarean sections are performed.

The purpose of the safe surgery checklist is to decrease errors and improve teamwork, communication, and coordination in operations, and the targeted HFs confirm improvement in all three areas.

3.3 E-MENTORING AND SUPPORT SYSTEMS FOR SERVICE PROVIDERS

UHI has increasingly been using ECHO to bridge the knowledge gaps of professionals in supported HFs, sharing critical, timely (as they occur) lifesaving information and data with health workers at different sites and geographical locations.

In FY4, UHI responded to requests to expand the number of ECHO sites within facilities to ensure that both female and male staff would have access to this technology given the increasing pressure to segregate health workers by sex. Two new sites were added.

In FY4, a virtual session was conducted with the ECHO India team to facilitate collaboration and knowledge exchange, allowing UHI to benefit from the experience of the well-established India TB program.

Insights gained from the ECHO sessions have helped ensure health care providers have the knowledge and skills to deliver high-quality care. In addition, interaction sets the stage for future cooperation and learning.

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3.4 CERTIFICATION AND QUALITY CARE

UHI continued to distribute certificates to qualified health care providers assessed as competent. During FY4, a total of 1,149 certificates were issued across various categories to health care providers who successfully completed the mentorship sessions and assessments.

3.5 INCREASED CLIENT SATISFACTION AND PUBLIC CONFIDENCE IN PUBLIC AND

PRIVATE HEALTH CARE

Four rounds of quarterly client exit interviews were conducted in seven service areas (FP, nutrition, TB, ANC, PNC, delivery, and vaccination), aiming to assess the client experience at UHI-supported HFs. The interviewers asked whether or not key components of quality services were addressed during care and about client satisfaction with the care they received. Key components assessed included waiting time of less than 30 minutes, friendly and professional treatment from providers, understandable explanations from providers, receipt of prescribed medications, and easy-to-understand explanations. Satisfaction was measured using a net promoter score (NPS).

During FY4, the survey was conducted in 92 HFs. In 49 of the 92 HFs (53.2 %) surveyed, all 11,148 clients interviewed reported the quality-of-care component. In addition, 51 of the 92 HFs (55.4%) reported that 8,974 (80.5%) clients expressed satisfaction levels of 8 or more on a 10-point Likert scale—surpassing the FY4 target of 47 HFs achieving 80% or more clients reporting an overall satisfaction rate.

The NPS is a metric used to measure customer satisfaction, for FY4 was 77.5%, a significant improvement over FY3, which had an NPS of 59.2%.

Similarly, the number of clients highly likely (score of 8–9 on a 10-point Likert scale) to recommend the use of HFs to friends and family members shows significant progress. In FY4, 76% of clients report that they are highly likely to recommend the use of HFs compared to 62.7% in FY3.

OBJECTIVE 4: IMPROVE AWARENESS, DEMAND, AND CARE-SEEKING FOR KEY SERVICES AND REFERRAL

4.1 INCREASED AWARENESS OF POSITIVE HEALTH-SEEKING BEHAVIOR AND HOME-BASED PRACTICES

● 234 platform: The Viamo platform (234 services) is a free, on-demand, 24/7, public service call line that allows

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Afghan citizens to access a variety of pre-recorded, actionable information on various health topics, including MNH, FP, and TB, in their own language and on their mobile phone, no matter how basic the phone. During FY4, 21,746 unique users dialed in, and 17,231 unique individuals listened to FP messages at the national level. UHI launched three new 234 bundle messages on MNCH including immunization, nutrition, and TB in September 2024.

● Self-care infoline: The infoline provides supportive messages to promote self-care behaviors during the antenatal (ANC infoline) and postnatal (PNC infoline) periods via pre-recorded voice messages delivered by mobile phone. The PNC infoline was piloted in six maternity hospitals in Kabul in FY2. It was expanded to additional areas in Kabul city in FY3 and ANC content was added.

In FY4, the infoline was scaled to Herat, Kandahar, Jalalabad, and Mazar-e-Sharif. During FY4, 61,275 mothers across the five cities accessed the infoline (32,349 pregnant women accessed the ANC infoline, while 28,926 new mothers accessed the PNC infoline).

4.2 INCREASED COMMUNITY ENGAGEMENT AND AWARENESS

Community mobilization: In FY4, 20 social mobilizers (10 female and 10 male) conducted 4,255 awareness-raising sessions (2,331 with women and 1,924 with men) with a total of 65,041 community members (40,341 female and 24,700 male) in Kabul, Herat, Mazar, and Jalalabad on health topics such as ANC, TB, FP, safe drinking water, child health, immunization, balanced food for mothers and children, malaria, diarrhea, oral rehydration solution preparation, COVID-19, danger signs of pregnancy, Congo hemorrhagic fever, and hygiene.

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SUMMARY OF ACHIEVEMENTS IN YEAR 4, ANNUAL REPORT (OCTOBER 01,

2023–SEPTEMBER 30, 2024)

Table 3: Performance on UHI Annual* Performance Plan and Report Indicators for FY4

Indicators Achievements in FY4

Deviation +/- 10% Explanation

OP 2.2.1: HL.7.1-2 – Percent of USG-assisted service delivery sites providing FP counseling and/or services

100% No 10%+/− deviation

OP 2.2.2: HL 7.1-1 – Number of CYP in USG-supported programs

227,319 Overachieved (target 155,090 in

FY4)

1. Potentially increased demand.

2. FP commodities are available in all UHI facilities.

3. Improve relevant staff capacity at the HFs in terms of FP counseling and providing respectful services.

4. In addition, the establishment of MLMCCs has contributed to the rise in acceptance of LARC methods, particularly post-partum implants and IUCDs.

OP 2.2.10: Number of children under 12 months of age who received the Penta 3 vaccine (custom)

103,079 No 10%+/− deviation

OP 2.2.11: HL 6.4-62 –

Number of children who received their first dose of MCV1 by 12 months of age in USG-assisted programs

94,959 No 10%+/− deviation

OP 2.2.17: HL.2.1-7 –

Childhood TB notifications

3,493 All form TB cases, 305 bacteriologically confirmed TB cases and 3,188 clinically diagnosed TB cases

Overachieved (target 2,718 in FY4)

1. Use of digital X-ray and GeneXpert for diagnosis; the sensitivity of GeneXpert test is high and the use of ULTRA cartridge is decreasing the testing time and increasing diagnosis.

2. The UHI team works closely with the

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Indicators Achievements in FY4

Deviation +/- 10% Explanation pediatrician specialists assigned by the TB control program in regional hospitals to screen and investigate TB cases among children.

3. The UHI team provides continuous technical support to the targeted HFs’ staff to avoid misdiagnosis of TB among children. The HFs will further strengthen the diagnosis using a child diagnostic algorithm (X-ray, contact history, signs/symptoms, tuberculin skin test, doctor judgment).

4. TB notification increased in Jalalabad; for instance, total TB cases increased from 2,334 in FY3 to 3,380 in PY4. In addition, TB notified cases among children increased from 1,304 in FY3 to 1,982 in

FY4.

OP 2.2.18: HL 2.4-1 – DR-TB

notifications

216 No 10%+/− deviation

OP 2.2.19: Number of TB notifications (public and private sector)

12,137 Overachieved (target 9,312 in FY4)

1. Strengthened and sustained TB services in existing HFs.

2. Timely supportive supervision and mentorship support for the HF staff.

3. Strengthened public and private HF referral system.

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in FY4

Deviation +/- 10% Explanation

4. Utilization of GeneXpert machines as primary diagnostic tool.

5. Utilization of CAD4TB for early screening of presumptive pulmonary TB cases.

OP 2.2.20: HL.2.1-9 – Contact investigation coverage rate

48.4% Overachieved (target 36% in FY4)

1. Through supportive supervision and mentorship visits to public and private HFs, staff were encouraged to visit the households of TB index cases.

2. Additional HF staff hired by UHI.

3. Regular transportation costs are provided to HF staff for household visits/active contact screening.

OP 2.2.21: HL.2.1-10 – TB

preventive treatment (TPT) enrollment

2,583 Overachieved (target 1,681 in FY4)

1. Number of TB index cases increased in PY4, therefore the number of children eligible for TPT increased.

OC 3.1.7: HL.2.5-1 – TB

treatment success rate

94% Overachieved (target 80% in FY4)

1. Focused on implementing a robust follow-up mechanism for TB patients during their treatment period.

2. Mobile top-up cards were provided for directly observed treatment, short-course (DOTS) nurses at the HFs to make prompt calls to patients.

3. Continued UHI support of the referral system, facilitating patient transfers to UHI-supported HFs.

4. Regular supply of anti-TB drug and lab consumables to HFs.

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in FY4

Deviation +/- 10% Explanation

OC 3.1.8: HL.2.4-4 – DR-TB

treatment success rate

70% No 10%+/− deviation

OP 3.2.3: HL 6.2-1 – Number of women giving birth who received uterotonics in the third stage of labor (or immediately after birth) through USG-supported programs

239,417 No 10%+/− deviation

OP 3.2.5: HL 6.3-1 – Number of newborns not breathing at birth who were resuscitated in USG-supported programs

13,068 No 10%+/− deviation

OP 3.2.6: HL 6.6-1 – Number of cases of child diarrhea treated in USG-assisted programs

154,135 No 10%+/−Deviation

OP 3.2.7: HL.6.6-64 –

Number of cases of childhood pneumonia treated in USG-assisted programs

84,089 Overachieved (target 74,236 in

FY4)

1.The quality of health care services day by day improved at the targeted HFs.

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INTRODUCTION

The goal of the Urban Health Initiative (UHI) is to improve health outcomes for people living in urban areas in Afghanistan, particularly women, children, and other vulnerable populations. The UHI consortium aims to achieve this goal by improving public and private health service delivery in the five major cities (Kabul, Mazar-e-Sharif, Herat, Kandahar, and Jalalabad) by strengthening the health service delivery ecosystem in urban areas to deliver high-quality services to the most vulnerable (Objective 1); improving access for vulnerable populations to critical primary and lifesaving secondary and referral care health services in urban areas through the public and private sectors (Objective 2); improving the quality of public and private critical primary and lifesaving secondary and referral health services in urban areas (Objective 3); and improving awareness, demand, and care-seeking for key services and referral (Objective 4).

WORK ENVIRONMENT IN FY4

The operating environment remained at a moderate risk for all project activities. Despite the increasingly challenging operating environment in the provinces, with additional decrees further restricting women, program activities continued with no significant direct or indirect security impact. The risk management team constantly records trends and changes in the security landscape and advises staff on mitigating behaviors.

Despite these severe challenges, UHI provided the needed support to female staff throughout the provinces so they could continue working in accordance with work plans and risk mitigation plans. The female staff of the Kabul office have been reporting regularly to cluster offices located in public and private hospitals. In the other provinces, coordination and information sharing with provincial public health directorates (PPHDs) is a key channel for the smooth implementation of UHI activities, and in most provinces, daily operations unfold uninterrupted, when conducted based on shared understanding with PPHDs and adherence to demands and restrictions.

The following sections describe the progress in FY4 (October 1, 2023–September 30, 2024).

ACTIVITY IMPLEMENTATION PROGRESS

OBJECTIVE 1: STRENGTHEN THE HEALTH SERVICE DELIVERY ECOSYSTEM IN URBAN AREAS TO DELIVER

HIGH-QUALITY SERVICES TO THE MOST VULNERABLE

1.1 ENSURE COORDINATIONWITH THE MINISTRY OF PUBLIC HEALTH

During FY4, the UHI project continued coordinating activities with the Ministry of Public Health (MoPH) at national and provincial levels. Project staff participated in national and city-level technical and coordination platforms and meetings. At the national level, this participation included the health cluster;

nutrition cluster; reproductive, maternal, newborn, child, and adolescent health (RMNCAH) task force;

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maternal and newborn health (MNH) technical subcommittee; MNH technical working group; family planning (FP) coordination committee; national RHCS coordination committee; national maternal and newborn death surveillance and response (MNDSR) committee; nutrition task force; child health task force; adolescent sexual and reproductive health coordination working group; Afghanistan Health Survey (AHS) coordination committee; and community-based health care (CBHC) and tuberculosis (TB) taskforce Additionally, the UHI team contributed to the revision and development of the misoprostol guideline, oxytocin guideline, antenatal care (ANC), postnatal care (PNC), and Labor Care Guide (LCG) guidelines: National Essential Newborn Care Package World Health Organization (WHO) Second Edition; and national kangaroo mother care (KMC) guidelines and led the Labor Care Guide technical working group. At the city level, the team’s participation included public health coordination committees (PHCCs); TB task force; CBHC subcommittee; RMNCAH subcommittee; Expanded Program on Immunization (EPI) subcommittee; nutrition subcommittee; health management information system (HMIS) subcommittee; Centers for Disease Control and Prevention/Emergency Preparedness and Response committee; Harmonized Quality Improvement Program committee; health subcluster;

nutrition subcluster; Directorate of Economy; Afghan Relief & Development coordination; quality improvement (QI)…